Okay, good morning. I think we can get started. Welcome to the third day of the 42nd Annual Raymond James Institutional Investors Conference. My name is Jayson Bedford. I cover medical devices here at Raymond James. It's really my pleasure to have with us the senior management team from Integra LifeSciences. From the company, we have the company's CFO, Carrie Anderson, and head of IR, Mike Beaulieu. So we're going to go straight fireside here. So maybe just to start, though, 2020 was, I think, a tough year for everyone from a growth and a volume perspective. But my sense is that Integra made 2020 a more productive year than most. Specifically, I'm thinking of the portfolio changes that enabled you to enter 2021 with what I would say is a more focused, cleaner business mix. Carrie, we always have a broad audience at this conference.
Can you describe in broad terms what happened in 2020 that makes you feel more confident in the business going into 2021?
Good morning, Jayson, and thanks for that initial question. We've had a stated objective for the business to grow 5%-7% on an organic basis, our top line. We have, I would say, in the past, maybe struggled to be consistent at being able to get there. But I think the steps that we have taken at the end of 2020, really, as you said, does provide a more focused, cleaner portfolio for us. And there were two transactions that we announced and basically executed in January that really started to transform our portfolio. The first of those was the divestiture of our ortho business. And then the second one was the acquisition of ACell. So very simply, we divested of a $100 million business that really wasn't growing. It was an attractive space, but we were more of a niche player.
We got the business as far as we could, but ultimately made a decision that it was going to require a lot more investment for us to get it to a position of growth. That business had been a negative grower, and in some cases, it was flat. So it certainly was not accretive to our 5%-7% growth aspirations. We divested that business, so divested a $100 million business, and swapped in place another $100 million business that's our ACell acquisition in the regenerative tissue space. Why that's really important is this is an area of the business that we think can actually grow really nicely for us. ACell is high single, low double-digit type of grower for us. It's in our core regenerative tissue space.
It's right centered in our sweet spot of where we are really strong in the inpatient side of tissue repair. And so it was a really nice complement bringing that in. And so the ortho divestiture happened January 4th. The acquisition of ACell closed on January 20th. And we think the swap out of those two respective businesses basically gives us even higher confidence now in the 5%-7%. The other thing, Jayson, I would say that was some bright spots amongst a pretty murky 2020 was related to some of the progress we made on gross margins. We expanded our margins 50 basis points in 2020, even with revenues down 10%. And I attribute that to some of the mixed changes that we're making in the business.
So we've talked a lot about how our gross margins should have the opportunity to get us to 70%, 72% adjusted gross margins. And we finished over 68% gross margins in 2020, even with COVID impacting our revenue pretty significantly. And a lot of that is some of the portfolio shifts that we're doing. For example, some of the discontinued products that we're getting out of our lower margin, lower growth products. And ultimately, some of this mix that we just talked about of the swap of the ortho for the ACell business will also start to help us from a positive mix perspective as well.
That's helpful. Just on the gross margin, do you expect base business margins at ACell to continue to improve?
Yeah. I mean, to your point, we had talked about the first year of the acquisition integration will be more neutral for us. So again, taking out ortho and dropping in ACell, giving us some time to integrate the business in the first year. But even with that, so even with that integration happening, I do expect that we'll see some gross margin improvement in 2021. A couple of things that are going to drive that gross margin improvement, the continuing mixed story that I just talked about, this will be probably the last year of any significant discontinued product impact. So we've really started to, over the last couple of years, really cleaned up our portfolio. And so this will be the last year.
But so it impacts our top line a bit when that discontinued product comes out, but it has a nice overall impact on our profitability story. So it's important that we finish that activity of SKU rationalization. The other thing is that we've talked a lot about in 2019 in our Tissue Technology business where we didn't have enough capacity to meet demand. The demand for our products was really quite strong, but we couldn't meet that demand. And so we made some investments late in 2019. And we used the time in 2020 basically to build more inventory. So while demand was low because of COVID, we kept many of our factories actually building these Tissue Technology products to give us the right safety stock level so that as the recovery happened, we were ready to be able to meet that demand.
And so we started to see some nice recovery in the Tissue Technology side of the business in the second half, and we expect that to be in 2021. The last piece that I would say in terms of some of that margin story is around the very last item that has been left to go on the Codman integration. So the Codman acquisition back in 2017 was a very transformative acquisition in our neurosurgery CSS side of the business. Basically, it moved us to the number one position in neurosurgery. But as a result of that, it was a carve-out from J&J, and there was a lot of integration work. Most of that is in the rearview mirror. But there's one last piece, and it's a TMA agreement, transition manufacturing service agreement, where J&J was actually still manufacturing some of our CSS portfolio.
We have stood up our own factory about 25 mi from the J&J facility, and we have started to convey employees over to the new facility. Basically, J&J employees now become Integra employees in our new factory. That transition will happen over the course of 2021, gradually phasing out of that TMA agreement, and that's a cost-plus arrangement, so once we are able to extract ourselves fully from that, obviously, that's going to be a margin lift for us. It is not a cliff, meaning I don't have to wait till the end of 2021 to see some of that improvement in gross margins as I get off of that. It's a phased approach to allow me to manage the risk of transitioning that over to our factory.
As we complete each phase of product transition, we'll come off of that TMA throughout 2021 with the expectation that by the end of the year, we'll be 100% off.
Okay. That's helpful. I'd like to dig deeper into the portfolio so investors can get a view of this 5%-7% sustainable growth profile that you're talking about. So neurosurgery, 50%-55% of sales. What do you view as the end market growth rate in neurosurgery?
Yeah. I would say it's a very large market in terms of our end market. We peg it somewhere between $3 billion and $4 billion. And that also includes our opportunity and instruments. And we're a very broad player in that space. We are a market leader in the space. Our portfolio covers a whole host of disease states, including brain tumors, hydrocephalus management, which is essentially the management of fluid on the brain, as well as traumatic brain injuries. And so our continuum of care, so if you think about our products, we cover anything from early diagnosis and planning to procedure-based tools and also post-diagnostic care in that space. So when you think about that whole market and you look at what's the growth rate of that, we expect that our growth rate will be about 3% to 5%. And that's been pretty consistent.
In 2019, we actually touched the top end, actually exceeded the top end of that range. And let me just maybe peel that back for you in terms of to talk about some of the different drivers of why we think that we could see growth rates in that higher end of that range more consistently. When you think about the neurosurgery market, there are some things that may be slow growing. Brain tumors, as an example, you might think of that as low single-digit type of growth of a disease state. But that growth rate is being impacted by aging population, as an example, and wider adoption of more technology. So you think of places like China and Japan where you actually see a growth rate that will be far above those.
And for Japan, as an example, for the last six quarters, we've been double-digit growth in Japan in our CSS part of the business. And that is even with a COVID pandemic going on. And I attribute that to not only some of the demographics of the aging population, but also the adoption of technology and some of the things we're doing from a business model perspective of changing from a distributor model to a direct model. And then there's other parts of the portfolio. When you think about hydrocephalus, that are benefiting from a change in technology there, moving from a traditional fixed valve approach to programmable valves. And that was one of the things that, as part of the Codman acquisition, we got in the portfolio a really nice suite of programmable valves.
We've been making new innovations around that, bringing new sizes of valves to bear in our portfolio. But that's one where, again, that growth can be very much influenced by the fact that the technology is driving that adoption and helping with a faster growth rate there. But that helps, Jayson.
It does. I guess a few questions on some of your comments there. CSS in Japan has been growing double-digit. How big is that business?
Yeah. It's a $60 million business for us. So it is the second largest country revenue for us outside of the United States. And again, it's been growing double digits. Now, I'm not suggesting that it's going to keep growing double digits, but I think it's going to be a high single-digit grower for us for quite some time. We just introduced a new product here, a LP shunt that is specifically for this market and will be used for this market. It's like a lumbar type of shunt. So this is an area that we're really excited about. And I think it's just shown to be such a resilient business model for us, driving a lot of our growth.
Okay. And the way you guys characterize revenue, dural access, neuromonitoring, advanced energy, CSF management, of those four buckets, which one is growing the fastest or where do you think you can grow the fastest?
Certainly, some of our growth drivers are in the hydrocephalus market, as I mentioned, with that shift of technology to programmable valves, coupled with the fact that we've got some new innovations, some new sizes that we're launching in that. Certainly, in the CSF management area, for sure. I would say in our dural access and repair, seeing some really nice growth there. You have to remember, some of that is because of Japan. We launched the first xenograft in the market there in the middle of 2019, and that's driven double-digit growth for us really across the rest of 2019 and into 2020. That's been a nice area for us. Even within dural access and repair, you have a DuraSeal product where half the market is still fibrin glue.
So there's an opportunity for that space, that particular sub-market, to continue to see some transition from fibrin glue to the use of more on-label type of solutions, and that bodes well for us. The other area that I would say that we're looking to see some nice growth is in the neuromonitoring space. This is where CereLink is going to be launched. So CereLink is a product that we originally launched in 2019, the middle of 2019, needed to make some modification, pulled it back from the launch, and are now relaunching here in the second half of 2021. It's a space that we know really well, Jayson. So I'm going to take you back to when we did the Codman acquisition. As part of that Codman acquisition, there were some FTC things that we needed to comply with.
There was a part of our business in the intracranial pressure monitoring space where we needed to divest. And so we had to make a decision. Do we divest of our legacy $30 million business in ICP monitoring, or do we keep the Codman innovation, CereLink? So we basically assessed the two products and made the decision to actually divest of our legacy $30 million business because we were so excited about the CereLink innovation here. So it's a space we know really well. And the space hasn't seen a lot of technology advancements over the last several years. So it's a ripe type of end market that really is begging for new technology. The CereLink ICP monitoring system has those technology advances. It has a better user interface. It is more sensitive. It has more data analytics around it.
And so this is a product that we think that really will be received well. And we're really excited about that. And we do hope that our expectation, my minimum expectation, is that we need to get back to $30 million on this product line. Now, it won't happen all in the first year, but it should exceed $30 million just based on the technology advancements. And we know where to go hunt. We know where all that installed base was. And so it's an opportunity for us, a really exciting opportunity as we relaunch this in the second half of the year.
$30 million. I'm just trying to think of the mix between capital and disposables. How long does it take to get to a $30 million? And that was a run rate? $30 million run rate?
Yeah. That was a run rate. Yeah. So I mean, usually, for our products, they usually take three to four years to reach peak sales. So even if I go back to 2019, it was one of our biggest years for product launches. We launched seven different products in CSS. And so those will continue to help us grow as we come out of COVID because, again, typically, when you're introducing new technology, it will take you three or four years to kind of reach peak revenue or kind of that run rate level. You're correct that CereLink does have it is a mix of capital as well as a disposable revenue stream because there are microsensors that go with it.
I don't have the mix of what that is, Jayson, but once we get the installed base going on that, it will continue to drive recurring revenue opportunity because you need it. There's a disposable microsensor that needs to be replaced in that.
Okay. And just in terms of why it came off the market in 2019, and does it require an additional filing here before you launch in the second half of 2021?
Yeah. We're already in the process of doing that. You are correct that it does require a new filing. There were some modifications we made to the device, nothing that had any concerns regarding patient safety. So I want to take that off the table. There was nothing regarding patient safety, just some interference on some of the electrical signals. And so essentially, we've addressed that and we'll be relaunching that here. And yes, it would take another filing, but that's part of our timeline as we think about the relaunch of that in the second half of the year.
Okay. And it's safe to assume that CereLink is kind of the biggest needle mover here from a new product perspective over the next year or two in neurosurgery?
Yeah. I mean, again, I go back that I still think some of the new products that we fully expect that those new products in 2019 that we launched will continue to be a driver of some of our NPIs as we go into 2021 and beyond in 2022. They will still be contributing to some nice growth because, again, they haven't reached their peak sales. But in terms of the absolute new product that we're introducing in 2021, my expectation is we'll get a nice lift as part of our guidance that we provided you in the second half because of this product. This is a major launch for us.
Okay. And Carrie, I know it's difficult just given the disparate nature of that neurosurgery market. What do you think your approximate share is in the areas in which you compete?
Yeah. I would just characterize it. We're market-leading in these positions. So the Codman acquisition was the most transformative acquisition we've done in Integra's history and really took us from a number three spot basically to number one, basically combining two very large businesses and moving to the number one position. So we are market-leading in this. And again, I think if you think about the broad spectrum of what I talked about of the continuum of care, there's not a player out there that has the depth of portfolio. There are a couple of large global players. And then in many of our smaller markets, or I would say specific geographic markets, you may find some smaller players there. But we clearly are the largest market-leading player there. We have a very large scale from a commercial perspective as well as a manufacturing presence.
From our perspective, we really are the drivers of innovation in this space. It's a very focused part of our portfolio that we really enjoy that leadership position. The example that I'd give you on driving innovation and why that market-leading position is really relevant in this space to drive innovation is had it not been for the Codman acquisition, we probably wouldn't have made these two smaller acquisitions that we did in the end of 2019. The one that I really want to talk about, we have the Arkis acquisition and we have the Rebound acquisition. I'm going to focus on the Rebound acquisition because this is one that can actually be pretty disruptive to the neurosurgery space as we think about the future and really can drive those higher growth rates for us. The Rebound acquisition, there's a product that's part of this.
You'll hear us. We call it the Aurora Surgiscope. So you're going to hear us talk about this a lot. We do have an investor day coming up on May 20th. So this will be an opportunity for us to talk a little bit more about this opportunity. And it was pre-revenue. So when we purchased it, it was pre-revenue. It needed some additional clinical study work that we're working on. It needed some additional modifications to the product that we have been working on. We will be doing a controlled release of that product here in late 2021. And there's two opportunities. So let me describe those two opportunities for you because they're actually both potentially disruptive for the space. The first and probably the larger of the two is minimally invasive surgical approach to neurosurgery.
So when you think about what happens in brain surgeries, let's use the example of resecting a tumor. Typically, that's done by an open craniotomy. So a large hole, an opening, in the brain to get access to that tumor. Well, think about now being able to get access to the brain through a small burr hole as opposed to a craniotomy, bringing, then, a Surgiscope, the Aurora Surgiscope, which is a trocar device. It gives you access to the brain as you go through that burr hole. And then you can bring instruments down to get access to the parts of the brain you need in terms of resecting a tumor, as an example. We think that this is pretty disruptive when you think about the traditional ways of neurosurgery. So that's one opportunity. The second opportunity is related to the stroke market, and it's related to cerebral hemorrhage.
So, deep bleeds on the brain where in the past, there really wasn't any medical intervention. It's mainly medical management. So when a patient has a stroke that is the result of a bleed and there's just no way to get to that area of the brain to get the blood off of the brain, this now is an approach that actually has the opportunity to get that blood off the brain quickly and produce better clinical outcomes, better patient outcomes, something different than just medical management. So that's the other exciting. And then the last thing I would say about this opportunity that the technology itself is so innovative, meaning it's completely disposable. It is a pack that you get the Surgiscope. On the Surgiscope, you have your own lighting and visualization, a camera that's attached to it, 100% disposable, plugs into the existing monitors in the operating room.
So no additional capital that's required. So we're really excited about this. Again, a limited release this year. So it's not going to be a big contributor to our revenue in 2021. But absolutely, we think this is a really great long-term driver of our revenue opportunity in the CSS space.
That's helpful. Thank you, Carrie. Let's just move down kind of your revenue here. Instruments, 10%-15% of sales. How do you view end market growth in this area? And I guess, was that contemplated in the 3%-5% that you mentioned earlier?
Yes, it is, and when I talk about instruments, it's a good business for us. We like the space. It is a little bit on the lower side of growth. It's low single digits. So when we talk about the 3%-5% that is comprehended, we think the neurosurgery part of the business will grow a little faster. The instrument side will grow a little bit slower for a balanced 3%-5% overall for CSS. There are benefits that we get in participating in the instrument space. We have a really large portfolio of instruments that range from high precision specialty instruments used in laparoscopic approaches, ENT, as well as other neurosurgery neuro procedures, and we also have a broader set of surgical instruments as well. It is a nice cash flow business for us, for sure.
Not a lot of direct sales that are needed to support the business. And it allows us to have some opportunities on the contracting sides with large hospital systems that actually allow us to bundle some other things in our portfolio. So it's a nice part of our portfolio that we think is very complementary to the CSS side of the business.
Okay. And I haven't done all the math, Carrie. So neurosurgery, probably 4%-6% growth, pure neurosurgery, and instruments kind of 1%-2%?
Yeah. I think that's the right way to think it. And I would say there are parts of the instruments that, as we think about our performance in 2019, that actually performed quite well, actually grew faster than the market. And we're still interested in looking on the peripheral of the instrument space, looking for opportunities that might be able to provide some opportunities to add to the portfolio that might have some higher growth than a low single digit. So still interested in that space because we think it's, again, a nice complementary fit with our neurosurgery piece.
Okay, and just the environment for capital equipment. I think most of your capital equipment falls in that instrument bucket. I feel like the impact of COVID on capital varies by company. Do you sense that hospitals are constrained for cash, or is it just a function they don't want to get trained and add a new piece of capital in the current environment?
Yeah, Jayson, just a reminder that our capital portion of our business is about 6% of our total revenue. So it's not a large piece of our revenue, but it is when we don't have million-dollar pieces of equipment. So the highest ASP for our capital equipment is in that $100,000-$200,000 range with our CUSA capital. That's our tissue ablation system. And that sits in the advanced energy space. It doesn't sit in instruments. It actually sits in the advanced energy. But you're right, there's other pieces that are we have a cranial stabilization unit. We have a dual lighting system that those fall in more in the instruments area. So I would say that the way I would characterize this is we think hospitals are basically waiting for just some better visibility as it relates to the risk of COVID surges.
We don't necessarily think it's tied to a cash flow issue per se, but being more conservative until they have more visibility around that risk of COVID surges. It's not like capital went to zero. We expected it when COVID hit initially back last year at this time. We anticipated that capital would be one of the ones that would be deferred the fastest, and it would be one of the slowest to recover. That has basically been what we've seen. But I would say we've still seen some nice recovery. So even between the third and the fourth quarter, we saw some really nice, I think it was 30% sequential improvement from the third quarter to the fourth quarter. But still, our capital was down a lot more than the rest of our portfolio. So I think it's going to take some time.
Our best view is that we'll continue to see some improvement, but it's going to be slow, and we probably won't see some more significant improvement until we get to the back half of 2021, where I think hospitals will have better visibility of if COVID is now more behind us than in front of us. I think we have really good pipeline visibility. Nothing has changed from a competitive standpoint for us. I just think of it as it's just extended the selling cycle, so the opportunities are absolutely there. We know where they are in our funnel. And it's just being a bit more patient until that faucet can turn back on and budgets can flow a little bit more for capital.
So the return to capital is more of a back half 2021 dynamic?
That's our anticipation. That's our expectation at this point, and certainly, we hope that's true because we're launching our new CereLink capital units in the back half of the year, and again, we think it hits a really nice sweet spot in that end market, and we're excited about that, but that would be a piece of our new capital equipment in that space in the second half of the year.
Okay. Tissue Technologies, this is where you've built up. It's now, what, 30% of sales if we include private label. I think this market is sometimes tough for investors to get their arms around. Can you just walk through the segments of this market that you play in, the respective growth profiles, and then maybe what ACell brings to the table?
Sure. We have one of the largest portfolios in the advanced tissue products. And let me just back up and talk about our technology platforms because I think as you think about the complexity of complex wounds and tissue repair, the opportunity is that we have a whole portfolio that we kind of bring to bear on a number of spaces. So let's talk about we have two bovine technology platforms that are part of the legacy Integra. The ACell acquisition brought a new porcine technology to bear. So now we've added another leg. And then we also have our fourth leg, which is the human amniotic platform. So four technology platforms to bring to bear in this space. So let me talk about some of the larger pockets within this broader technology space we call Tissue Technology. The first is around complex wound and tissue reconstruction.
This includes procedures that are in the burn and in trauma centers, but it also includes chronic wounds. Most of these markets, there's a lot of these markets that may grow anywhere from the low single digits to all the way up to high single, even low double digit growth. Full spectrum there of growth opportunities. The next area is in surgical reconstruction, which means plastic reconstruction, surgery, breast reconstruction, or ab wall repair or hernia repair. These are relatively new markets for Integra. I'll use the example for hernia repair in this example that most of the market is using a synthetic mesh. We have a xenograft product that is brought to bear. Our opportunity is more of the adoption of that technology in that space.
And so we think that in the surgical reconstruction area, as it looks at the breast reconstruction as well as hernia repair, it has the opportunity to grow mid- to high-single-digits for us because, again, some of this is the technology adoption that we bring to relevance to these particular markets. And then we also have a peripheral nerve market as well. We were actually the pioneers in the nerve space. But over the last couple of years, we have put our focus elsewhere in the portfolio. But we are now becoming more focused on the segment, and we look to expand our portfolio with new products. So that's a really quick overview. I think our sweet spot is in the inpatient setting for sure. We also do outpatient, but our really sweet spot is on the inpatient setting.
And so when you think about the ACell acquisition, as I mentioned, it brought a new technology, the porcine technology platform to Integra. But it also was centered on the inpatient opportunity. And so we think it's really quite complementary. So let me talk about the couple of products that we think we're really excited about. The first is a product called MicroMatrix. And it is a powder formulation. So everything in our portfolio is more of a sheet formulation. This is our first powder formulation. They call it the pixie dust, that it's used to basically spur some growth or some regenerative capabilities in terms of wound healing. And so in some cases, it's used by itself. In other cases, it's used in conjunction with the sheets to continue to spur wound healing.
So this part of their portfolio is about a little bit less than 50% of their total revenue. Again, in 2019, it was about $100 million of revenue. So think about it as just under 50% being this MicroMatrix powder formulation. The other part of the portfolio, which is about 25% of their revenue, is in the hernia repair. Gentrix is the product name. And why we're excited about this is that they have an indication for laparoscopic approach for hernia repair. We do not have that indication for our product. So in my view, that it really helps us get comfortable with a portfolio in Tissue Technology that can grow high single digits and in some cases, even touch some of the low double digit growth areas across the whole portfolio on the Tissue Technology side.
Tissue Technology as a whole, you expect high single? Is that a fair way to look at it?
Yeah. I mean, we'll give some more information on our May 20th investor call. But I would say my expectation is certainly high single digits with some opportunity maybe to get to some low double digits in certain product lines. But high single digits is what my expectation will be. And I think the blend of the 3%-5% on the CSS side coupled with high single digits on the Tissue Technology side with greater confidence now that we've got the ortho business out of the portfolio, which was a drag. It was a negative grower to a flat grower, gives us that higher confidence now that we can grow sustainably at that 5%-7%. Now, in 2021, I don't think we'll see that in the first half of the year just because we're still living with the COVID overhang.
But as we provided guidance on our fourth quarter call for 2021, we talked about a slow, gradual recovery in the first half and essentially being with COVID behind us in the second half. And so the second half, our expectation is that we can start to grow in that 5%-7% range.
Okay. But clearly, Carrie, you have a pretty easy comp in the second quarter.
No, I'm glad you asked. Yeah, I'm glad you brought that up. My references were relative to 2019. So the guidance that we provided, yes, was to 2020, a year-over-year comparison. But my comments in terms of being able to get to some nice growth in the second half is relative to 2019. So if you took the guidance that we provided, we talked about double-digit growth in 2021 compared to 2020. But there was a question that was on our earnings call that asked, "Well, how do you translate to that guidance relative to 2019?" And the answer was that on an organic basis, the expectation is 3%-4% organic growth for the full year. And we talked about the first half would be more of a gradual recovery.
The implied guidance there is that the second half will essentially be more COVID-free, and we can see some nice growth there. The implication is lower growth in the first half returning to a more sustainable growth in the second half of the year relative to 2019.
Okay. So that's where you hit the 5%- 7%, second half 2021 versus second half 2019.
Yeah. I mean, and again, we talked about that our guidance range does assume that there's no additional COVID surges, that we continue to see a recovery going forward. And so there's certainly some risk as it relates to some of the variants that are out there. But at this point, we don't have any better crystal ball than anybody else does. And so at this point, our view is that we can get this behind us and that second half will be more normalized for us.
Okay. Okay. I guess let's kind of we have a couple of minutes left here. I think a big part of the ACell acquisition is the potential leverage that it offers. So at what point do you feel comfortable in reducing the cost structure at ACell?
Yeah. Well, that's already started, Jayson. So we closed the transaction on January 20th. One of the important things for us is to try to minimize as much as possible the disruption on the top line. And so it was really important for us to make sure that we got kind of all the players situated and we got territories defined. We got comp plans put in place. So ACell had around 200 reps. And so we basically took over just a smaller portion of that. We only took about 40% of that sales team over that conveyed over. So again, a large amount of the lift has already been done in terms of making the calls on the sales reps and getting them conveyed over. We leveraged a February national sales training meeting to start the education on the portfolio.
So in a lot of cases, the portfolio training was on the Integra side, learning the ACell portfolio as well as the ACell reps that conveyed over, learning the Integra portfolio. But a lot of the focus was around the legacy Integra field reps basically being trained on the portfolio. So again, all of that body of work has been done. Now it's about selling. It's about getting our marketing and our value propositions put in place in terms of how do we differentiate the different products in ACell relative to the Integra portfolio. We have some infrastructure lift that we need to do in the second quarter relative to integrating the ERP system, so getting the back office work integrated. So when you think about it, I go back to the fact that this is on our call points.
So it shouldn't be a surprise that the majority of the synergies where it's going to come from is on the sales synergy side. That's where the majority of the synergies will come from, as well as the opportunity to integrate them into our infrastructure. That will be the second biggest area. My expectation is that by the time we get to the fourth quarter, we will have realized our full run rate synergy potential here in terms of the cost structure. So we've talked about taking about 40% of their cost structure out. They were a business that had really healthy gross margins, but essentially break even from an EBITDA perspective because they didn't have scale. We have the scale, and that's the opportunity for us to bring them in, integrate them. We like the gross margins.
It fits very, very well with the gross margins of our existing Tissue Technology portfolio, and it's all about just leveraging that SG&A kind of back office piece and the sales piece that we're working on.
Okay. Great. We're bumping up against our allotted time. Always a dynamic story, always a lot going on with Integra. So Carrie, Mike, appreciate the time this morning.
Thank you so much, Jayson.
Thanks, Jayson.